Provider Demographics
NPI:1871369645
Name:LUCKETT, ROXANNE
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:LUCKETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 TRACE COLONY PARK DR STE B
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-8810
Mailing Address - Country:US
Mailing Address - Phone:601-756-4908
Mailing Address - Fax:
Practice Address - Street 1:158 SHILOH FIRETOWER RD
Practice Address - Street 2:
Practice Address - City:FOXWORTH
Practice Address - State:MS
Practice Address - Zip Code:39483-4782
Practice Address - Country:US
Practice Address - Phone:601-756-4908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-01
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health